Propensity Score-Weighted Analysis of Postoperative Infection in Patients With and Without Preoperative Urine Culture.

Importance: Although recent guidelines recommend against performance of preoperative urine culture before nongenitourinary surgery, many clinicians still order preoperative urine cultures and prescribe antibiotics for treatment of asymptomatic bacteriuria in an effort to reduce infection risk. Objective: To assess the association between preoperative urine culture testing and postoperative urinary tract infection (UTI) or surgical site infection (SSI), independent of baseline patient characteristics or type of surgery. Design, Setting, and Participants: This cohort study analyzed surgical procedures performed from January 1, 2017, to December 31, 2019, at any of 112 US Department of Veterans Affairs (VA) medical centers. The cohort comprised VA enrollees who underwent major elective noncardiac, nonurological operations. Machine learning and inverse probability of treatment weighting (IPTW) were used to balance the characteristics between those who did and did not undergo a urine culture. Data analyses were performed between January 2023 and January 2024. Exposures: Performance of urine culture within 30 days prior to surgery. Main Outcomes and Measures: The 2 main outcomes were UTI and SSI occurring within 30 days after surgery. Weighted logistic regression was used to estimate odds ratios (ORs) for postoperative infection based on treatment status. Results: A total of 250 389 VA enrollees who underwent 288 858 surgical procedures were included, with 88.9% (256 753) of surgical procedures received by males and 48.9% (141 340) received by patients 65 years or older. Baseline characteristics were well balanced among treatment groups after applying IPTW weights. Preoperative urine culture was performed for 10.5% of surgical procedures (30 384 of 288 858). The IPTW analysis found that preoperative urine culture was not associated with SSI (adjusted OR [AOR], 0.99; 95% CI, 0.90-1.10) or postoperative UTI (AOR, 1.18; 95% CI, 0.98-1.40). In analyses limited to orthopedic surgery and neurosurgery as a proxy for prosthetic implants, the adjusted risks for UTI and SSI were also not associated with preoperative urine culture performance. Conclusions and Relevance: This cohort study found no association between performance of a preoperative urine culture and lower risk of postoperative UTI or SSI. The results support the deimplementation of urine cultures and associated antibiotic treatment prior to surgery, even when using prosthetic implants.

Intravenous Diltiazem Versus Metoprolol in Acute Rate Control of Atrial Fibrillation/Flutter and Rapid Ventricular Response: A Meta-Analysis of Randomized and Observational Studies.

BACKGROUND: Atrial fibrillation (AF) and/or atrial flutter (AFL) with rapid ventricular response (RVR) is a condition that often requires urgent treatment. Although guidelines have recommendations regarding chronic rate control therapy, recommendations on the best choice for acute heart rate (HR) control in RVR are unclear. METHODS: A systematic search across multiple databases was performed for studies evaluating the outcome of HR control (defined as HR less than 110 bpm and/or 20% decrease from baseline HR). Included studies evaluated AF and/or AFL with RVR in a hospital setting, with direct comparison between intravenous (IV) diltiazem and metoprolol and excluded cardiac surgery and catheter ablation patients. Hypotension (defined as systolic blood pressure less than 90 mmHg) was measured as a secondary outcome. Two authors performed full-text article review and extracted data, with a third author mediating disagreements. Random effects models utilizing inverse variance weighting were used to calculate odds ratios (OR) and 95% confidence intervals (CI). Heterogeneity was assessed using the I2 test. RESULTS: A total of 563 unique titles were identified through the systematic search, of which 16 studies (7 randomized and 9 observational) were included. In our primary analysis of HR control by study type, IV diltiazem was found to be more effective than IV metoprolol for HR control in randomized trials (OR 4.75, 95% CI 2.50-9.04 with I2 = 14%); however, this was not found for observational studies (OR 1.26, 95% CI 0.89-1.80 with I2 = 55%). In an analysis of observational studies, there were no significant differences between the two drugs in odds of hypotension (OR 1.12, 95% CI 0.51-2.45 with I2 = 18%). CONCLUSION: While there was a trend toward improved HR control with IV diltiazem compared with IV metoprolol in randomized trials, this was not seen in observational studies, and there was no observed difference in hypotension between the two drugs.

Effectiveness and acceptability of intranasal povidone-iodine decolonization among fracture fixation surgery patients to reduce Staphylococcus aureus nasal colonization.

We evaluated povidone-iodine (PVI) decolonization among 51 fracture-fixation surgery patients. PVI was applied twice on the day of surgery. Patients were tested for S. aureus nasal colonization and surveyed. Mean S. aureus concentrations decreased from 3.13 to 1.15 CFU/mL (P = .03). Also, 86% of patients stated that they felt neutral or positive about their PVI experience.

Prevalence of One-Year Mortality after Implantable Cardioverter Defibrillator Placement: An Opportunity for Palliative Care?

Background: Current guidelines recommend against placement of implantable cardioverter defibrillators in patients with a life expectancy less than one year. These patients may benefit from early palliative care services; however, identifying this population is challenging. Objective: Determine whether a validated prognostic tool, based on patient factors and health care utilization from electronic medical records, accurately predicts one-year mortality at the time of implantable cardioverter defibrillator placement. Design: We used the United States (U.S.) Veterans Administration's "Care Assessment Needs" one-Year Mortality Score to identify patients at high risk of mortality (score ≥95) before their procedure. Data were extracted from the Corporate Data Warehouse. Logistic regression was used to assess the odds of mortality at different score levels. Setting/Subjects: Patients undergoing a new implantable cardioverter defibrillator procedure between October 1, 2015 and September 30, 2017 in the U.S. Veterans Administration. Results: Of 3194 patients with a new implantable cardioverter defibrillator placed, 657 (21.8%) had a score ≥95. The mortality rate among these patients was 151/657 (22.9%) compared with 281/3194 (8.8%) for all patients undergoing a new implantable cardioverter defibrillator procedure. Patients with a score ≥95 had 14.0 (95% confidence interval 8.0-24.4) higher odds of death within one year of the procedure compared with those with a score ≤60. Conclusions: The "Care Assessment Needs" Score is a valid predictor of one-year mortality following implantable cardioverter defibrillator procedures. Integrating its use into the management of Veterans Administration (VA) patients considering implantable cardioverter defibrillators may improve shared decision making and engagement with palliative care.

Association of Nonobstructive Chronic Bronchitis With All-Cause Mortality: A Systematic Literature Review and Meta-analysis.

BACKGROUND: The effect of nonobstructive chronic bronchitis (CB) on mortality is unclear. RESEARCH QUESTION: Is nonobstructive CB associated with increased all-cause mortality? STUDY DESIGN AND METHODS: We conducted a systematic literature review and meta-analysis to assess the association of nonobstructive CB and all-cause mortality. We searched for articles that included both CB and mortality in the title, abstract, or both in PubMed and EMBASE. We excluded studies in which participants demonstrated obstructive spirometry findings and studies in which CB and mortality were not defined. We used the Newcastle-Ottawa Quality Assessment Scale to assess study quality. We pooled adjusted hazard ratios (HRs) using the random effects model and inverse variance weighting. We conducted stratified analysis by the definition of CB and smoking status. We used Cochran's Q and I2 to assess for heterogeneity. We assessed publication bias by visual inspection of a funnel plot. RESULTS: Of 5,014 titles identified, eight fulfilled the inclusion and exclusion criteria. Overall nonobstructive CB was associated with all-cause mortality (HR, 1.37; 95% CI, 1.26-1.50) with no statistically significant heterogeneity (P = .14; I2 = 29%). Nonobstructive CB was associated with increased mortality in studies that defined CB as any respiratory symptoms (broad definition; HR, 1.28; 95% CI, 1.10-1.48; I2 = 0%) as well as in the rest of the studies (HR, 1.40; 95% CI, 1.26-1.56; I2 = 37%). Nonobstructive CB was associated with increased mortality in ever smokers (HR, 1.49; 95% CI, 1.35-1.64; I2 = 0%), but was not associated with increased mortality in never smokers (HR, 1.22; 95% CI, 0.90-1.66), and moderate heterogeneity was found (P = .10; I2 = 49%). The funnel plot did not indicate evidence of a publication bias because it showed symmetrical distribution of studies. INTERPRETATION: Nonobstructive CB is associated with increased all-cause mortality, and this association seems to be present only in current and former smokers. Further research should investigate whether this high-risk population may benefit from early therapeutic intervention. TRIAL REGISTRY: PROSPERO; No.: CRD42021253596; URL: www.crd.york.ac.uk/prospero.

Short-term effectiveness of COVID-19 vaccines in immunocompromised patients: A systematic literature review and meta-analysis.

OBJECTIVES: We aimed to assess the short-term effectiveness of COVID-19 vaccines among immunocompromised patients to prevent laboratory-confirmed symptomatic COVID-19 infection. METHODS: Systematic review and meta-analysis. We calculated the pooled diagnostic odds ratio [DOR] (95% CI) for COVID-19 infection between immunocompromised patients and healthy people or those with stable chronic medical conditions. VE was estimated as 100% x (1-DOR). We also investigated the rates of developing anti-SARS-CoV-2 spike protein IgG between the 2 groups. RESULTS: Twenty studies evaluating COVID-19 vaccine response, and four studies evaluating VE were included in the meta-analysis. The pooled DOR for symptomatic COVID-19 infection in immunocompromised patients was 0.296 (95% CI: 0.108-0.811) with an estimated VE of 70.4% (95% CI: 18.9%- 89.2%). When stratified by diagnosis, IgG antibody levels were much higher in the control group compared to immunocompromised patients with solid organ transplant (pOR 232.3; 95% Cl: 66.98-806.03), malignant diseases (pOR 42.0, 95% Cl: 11.68-151.03), and inflammatory rheumatic diseases (pOR 19.06; 95% Cl: 5.00-72.62). CONCLUSIONS: We found COVID-19 mRNA vaccines were effective against symptomatic COVID-19 among the immunocompromised patients but had lower VE compared to the controls. Further research is needed to understand the discordance between antibody production and protection against symptomatic COVID-19 infection.

Development of a fully automated surgical site infection detection algorithm for use in cardiac and orthopedic surgery research.

OBJECTIVE: To develop a fully automated algorithm using data from the Veterans' Affairs (VA) electrical medical record (EMR) to identify deep-incisional surgical site infections (SSIs) after cardiac surgeries and total joint arthroplasties (TJAs) to be used for research studies. DESIGN: Retrospective cohort study. SETTING: This study was conducted in 11 VA hospitals. PARTICIPANTS: Patients who underwent coronary artery bypass grafting or valve replacement between January 1, 2010, and March 31, 2018 (cardiac cohort) and patients who underwent total hip arthroplasty or total knee arthroplasty between January 1, 2007, and March 31, 2018 (TJA cohort). METHODS: Relevant clinical information and administrative code data were extracted from the EMR. The outcomes of interest were mediastinitis, endocarditis, or deep-incisional or organ-space SSI within 30 days after surgery. Multiple logistic regression analysis with a repeated regular bootstrap procedure was used to select variables and to assign points in the models. Sensitivities, specificities, positive predictive values (PPVs) and negative predictive values were calculated with comparison to outcomes collected by the Veterans' Affairs Surgical Quality Improvement Program (VASQIP). RESULTS: Overall, 49 (0.5%) of the 13,341 cardiac surgeries were classified as mediastinitis or endocarditis, and 83 (0.6%) of the 12,992 TJAs were classified as deep-incisional or organ-space SSIs. With at least 60% sensitivity, the PPVs of the SSI detection algorithms after cardiac surgeries and TJAs were 52.5% and 62.0%, respectively. CONCLUSIONS: Considering the low prevalence rate of SSIs, our algorithms were successful in identifying a majority of patients with a true SSI while simultaneously reducing false-positive cases. As a next step, validation of these algorithms in different hospital systems with EMR will be needed.

Disparities in breast cancer stage at diagnosis between immigrant and native-born women: A meta-analysis.

PURPOSE: To synthesize existing observational evidence to identify disparities in stage at breast cancer diagnosis between foreign- and native-born women. We hypothesized immigrant women would be less likely than natives to be diagnosed at a localized stage. METHODS: Systematic searches for studies detailing stage at breast cancer diagnosis by birthplace in PubMed, Embase, and Web of Science yielded 11 relevant cohort studies from six countries. Odds ratios were pooled using random effects models. RESULTS: Foreign-born women were 12% less likely to be diagnosed with breast cancer at a localized stage than natives (OR 0.88, 95% CI 0.82-0.95). A similar disadvantage was observed in immigrants from Asia, Eastern Europe, Latin America and the Caribbean, and developing or in transition nations; immigrants from developed countries experienced the least disparity. CONCLUSIONS: This meta-analysis confirmed the presence of significant differences in breast cancer stage at diagnosis as per nativity. Across diverse immigrant groups and host countries, foreign-born women were significantly less likely to be diagnosed with localized breast cancer than native women; the magnitude of the disparity varied by region and economic condition of immigrants' birthplace.

Meta-Analysis of VTE Risk: Ovarian Cancer Patients by Stage, Histology, Cytoreduction, and Ascites at Diagnosis.

Venous thromboembolisms (VTEs) have been a leading secondary cause of death among ovarian cancer patients, prompting multiple studies of risk factors. The objective of this meta-analysis is to quantify the associations between VTE and the most commonly reported risk factors among ovarian cancer patients. PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) were used to identify observational studies. Two reviewers independently abstracted data and assessed quality via the Newcastle-Ottawa tool. A random effects model was used to calculate the pooled odds ratios for VTE with each of the following exposures: advanced cancer stage, clear cell histology, serous histology, ascites at diagnosis, and complete cytoreduction. The I 2 and Q tests were used to evaluate heterogeneity. Twenty cohort studies with 6,324 total ovarian cancer patients, 769 of whom experienced a VTE, were included. The odds of VTE in ovarian cancer patients were higher among patients with cancer stage III/IV (versus cancer stage I/II, pooled odds ratio (OR) 2.73; 95% CI 1.84-4.06; I 2= 64%), clear cell (versus nonclear cell) histology (OR 2.11; 95% CI 1.55-2.89; I 2 = 6%), and ascites (versus no ascites) at diagnosis (OR 2.12; 95% CI 1.51-2.96; I 2 = 32%). Serous (versus nonserous) histology (OR 1.26; 95% CI 0.91-1.75; I 2 = 42%) and complete (versus incomplete) cytoreduction (OR 1.05; 95% CI 0.27-4.11; I 2 = 88%) were not associated with VTE. This meta-analysis quantifies the significantly elevated odds of VTE in ovarian cancer patients with advanced stage at diagnosis, clear cell histology, and ascites at diagnosis. Further studies are needed to account for confounders and inform clinical decision-making tools.

Novel Method to Flag Cardiac Implantable Device Infections by Integrating Text Mining With Structured Data in the Veterans Health Administration's Electronic Medical Record.

Importance: Health care-associated infections (HAIs) are preventable, harmful, and costly; however, few resources are dedicated to infection surveillance of nonsurgical procedures, particularly cardiovascular implantable electronic device (CIED) procedures. Objective: To develop a method that includes text mining of electronic clinical notes to reliably and efficiently measure HAIs for CIED procedures. Design, Setting, and Participants: In this multicenter, national cohort study using electronic medical record data for patients undergoing CIED procedures in Veterans Health Administration (VA) facilities for fiscal years (FYs) 2016 and 2017, an algorithm to flag cases with a true CIED-related infection based on structured (eg, microbiology orders, vital signs) and free text diagnostic and therapeutic data (eg, procedure notes, discharge summaries, microbiology results) was developed and validated. Procedure data were divided into development and validation data sets. Criterion validity (ie, positive predictive validity [PPV], sensitivity, and specificity) was assessed via criterion-standard manual medical record review. Exposures: CIED procedure. Main Outcomes and Measures: The concordance between medical record review and the study algorithm with respect to the presence or absence of a CIED infection. CIED infection in the algorithm included 90-day mortality, congestive heart failure and nonmetastatic tumor comorbidities, CIED or surgical site infection International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis codes, antibiotic treatment of Staphylococci, a microbiology test of a cardiac specimen, and text documentation of infection in specific clinical notes (eg, cardiology, infectious diseases, inpatient discharge summaries). Results: The algorithm sample consisted of 19 212 CIED procedures; 15 077 patients (78.5%) were White individuals, 1487 (15.5%) were African American; 18 766 (97.7%) were men. The mean (SD) age in our sample was 71.8 (10.6) years. The infection detection threshold of predicted probability was set to greater than 0.10 and the algorithm flagged 276 of 9606 (2.9%) cases in the development data set (9606 procedures); PPV in this group was 41.4% (95% CI, 31.6%-51.8%). In the validation set (9606 procedures), at predicted probability 0.10 or more the algorithm PPV was 43.5% (95% CI, 37.1%-50.2%), and overall sensitivity and specificity were 94.4% (95% CI, 88.2%-97.9%) and 48.8% (95% CI, 42.6%-55.1%), respectively. Conclusions and Relevance: The findings of this study suggest that the method of combining structured and text data in VA electronic medical records can be used to expand infection surveillance beyond traditional boundaries to include outpatient and procedural areas.

Risk of Recurrent Staphylococcus aureus Prosthetic Joint Infection in Rheumatoid Arthritis Patients-A Nationwide Cohort Study.

BACKGROUND: Treatment of rheumatoid arthritis (RA) often involves immune-suppressive therapies. Concern for recurrent prosthetic joint infection (PJI) in RA patients might be high and could reduce use of joint implantation in these patients. We aimed to evaluate the risk of recurrence of PJI in RA patients compared with osteoarthritis (OA) patients by utilizing a large health care system. METHODS: We conducted a retrospective cohort study of all patients admitted for a Staphylococcus aureus PJI who underwent debridement, antibiotics, and implant retention (DAIR) or 2-stage exchange (2SE) between 2003 and 2010 at 86 Veterans Affairs Medical Centers. Both RA patients and the comparison group of osteoarthritis (OA) patients were identified using International Classification of Diseases, Ninth Revision, codes. All index PJI and recurrent positive cultures for S. aureus during 2 years of follow-up were validated by manual chart review. A Cox proportional hazards regression model was used to compare the time to recurrent PJI for RA vs OA. RESULTS: In our final cohort of 374 veterans who had either DAIR or 2SE surgery for their index S. aureus PJI, 11.2% had RA (n = 42). The majority of the cohort was male (97.3%), and 223 (59.6%) had a methicillin-susceptible S. aureus PJI. RA patients had a similar risk of failure compared with OA patients, after adjusting for covariates (hazard ratio, 0.81; 95% confidence interval, 0.48-1.37). CONCLUSIONS: Prior diagnosis of RA does not increase the risk of recurrent S. aureus PJI. Further studies are needed to evaluate the effect of different RA therapies on outcomes of episodes of PJI.

Infectious complications of laparoscopic and robotic hysterectomy: a systematic literature review and meta-analysis.

OBJECTIVE: We performed a systematic review of the literature and meta-analysis of the infectious complications of hysterectomy, comparing robotic-assisted hysterectomy to conventional laparoscopic-assisted hysterectomy. METHODS: We searched PubMed, CINAHL, CDSR, and EMBASE through July 2018 for studies evaluating robotic-assisted hysterectomy, laparoscopic-assisted hysterectomy, and infectious complications. We employed random-effect models to obtain pooled OR estimates. Heterogeneity was evaluated with I2 estimation and the Cochran Q statistic. Pooled ORs were calculated separately based on the reason for hysterectomy (eg, benign uterine diseases, endometrial cancer, and cervical cancer). RESULTS: Fifty studies were included in the final review for the meta-analysis with 176 016 patients undergoing hysterectomy. There was no statistically significant difference in the number of infectious complication events between robotic-assisted hysterectomy and laparoscopic-assisted hysterectomy (pooled OR 0.97; 95 % CI 0.74 to 1.28). When we performed a stratified analysis, similar results were found with no statistically significant difference in infectious complications comparing robotic-assisted hysterectomy to laparoscopic-assisted hysterectomy among patients with benign uterine disease (pooled OR 1.10; 95 % CI 0.70 to 1.73), endometrial cancer (pooled OR 0.97; 95 % CI 0.55 to 1.73), or cervical cancer (pooled OR 1.09; 95 % CI 0.60 to 1.97). CONCLUSION: In our meta-analysis the rate of infectious complications associated with robotic-assisted hysterectomy was no different than that associated with conventional laparoscopic-assisted hysterectomy.

Infectious Complications of Conventional Laparoscopic vs Robotic Laparoscopic Prostatectomy: A Systematic Literature Review and Meta-Analysis.

BACKGROUND: Recent studies have shown that using minimally invasive surgical techniques (conventional laparoscopy or robotic) for prostatectomy is associated with lower perioperative complication rates compared with open radical retropubic prostatectomy. However, differences in infectious complications between these minimally invasive approaches are not well characterized. To study this further, we performed a systematic review of the literature and meta-analysis of the infectious complications of prostatectomy, comparing robotic prostatectomy (RP) with conventional laparoscopic prostatectomy (LP). METHODS: We searched PubMed, CINAHL, CDSR, and EMBASE through September 2018 for studies evaluating minimally invasive prostatectomy and infectious complications. We employed random-effect models to obtain pooled odds ratio (pOR) estimates. Heterogeneity was evaluated with I2 estimation and the Cochran Q statistic. pORs were calculated separately based on the indication for prostatectomy. RESULTS: Fifteen studies were included in the final review for the meta-analysis with 14,121 patients undergoing minimally invasive prostatectomy. There was no statistically significant difference in the number of infectious complication events between RP and LP (pOR 0.94; 95% CI 0.50, 1.76). When we performed a stratified analysis, similar results were found with no statistically significant difference in infectious complications comparing RP with LP among patients with prostate cancer (pOR 0.73; 95% CI 0.43, 1.24). We observed that infectious complications were nearly threefold higher with the robotic approach in earlier studies (published between 2007 and 2012, pOR 2.81; 95% CI 1.07, 7.39), but no significant difference was found in later studies (between 2013 and 2018, pOR 0.80, 95% CI 0.40, 1.57). CONCLUSIONS: The rate of infectious complications associated with RP was no different than that associated with conventional LP.

Association Between Hospital and Surgeon Volume and Rectal Cancer Surgery Outcomes in Patients With Rectal Cancer Treated Since 2000: Systematic Literature Review and Meta-analysis.

BACKGROUND: Previous reviews and meta-analyses, which predominantly focused on patients treated before 2000, have reported conflicting evidence about the association between hospital/surgeon volume and rectal cancer outcomes. Given advances in rectal cancer resection, such as total mesorectal excision, it is essential to determine whether volume plays a role in rectal cancer outcomes among patients treated since 2000. OBJECTIVE: The purpose of this study was to determine whether there is an association between hospital/surgeon volume and rectal cancer surgery outcomes among patients treated since 2000. DATA SOURCES: We searched PubMed and EMBASE for articles published between January 2000 and December 29, 2017. STUDY SELECTION: Articles that analyzed the association between hospital/surgeon volume and rectal cancer outcomes were selected. INTERVENTION: Rectal cancer resection was the study intervention. MAIN OUTCOME MEASURES: The outcome measures of this study were surgical morbidity, postoperative mortality, surgical margin positivity, permanent colostomy rates, recurrence, and overall survival. RESULTS: Although 2845 articles were retrieved and assessed by the search strategy, 21 met the inclusion and exclusion criteria. There was a significant protective association between higher hospital volume and surgical morbidity (OR = 0.80 (95% CI, 0.70-0.93); I = 35%), permanent colostomy (OR = 0.51 (95% CI, 0.29-0.92); I = 34%), and postoperative mortality (OR = 0.62 (95% CI, 0.43-0.88); I = 34%), and overall survival (OR = 0.99 (95% CI, 0.98-1.00); I = 3%). Stratified analysis showed that the magnitude of association between hospital volume and rectal cancer surgery outcomes was stronger in the United States compared with other countries. Surgeon volume was not significantly associated with overall survival. The articles included in this analysis were high quality according to the Newcastle-Ottawa scale. Funnel plots suggested that the potential for publication bias was low. LIMITATIONS: Some articles included rectosigmoid cancers. CONCLUSIONS: Among patients diagnosed since 2000, higher hospital volume has had a significant protective effect on rectal cancer surgery outcomes.

A systematic review and meta-analysis of the association between vitamin A intake, serum vitamin A, and risk of liver cancer.

BACKGROUND: Previous evidence supports that vitamin A decreases the risk of several types of cancer. However, the association between vitamin A and liver cancer is inconclusive. AIM: This systematic review and meta-analysis summarizes the existing literature, discussing the association between vitamin A intake, serum vitamin A, and liver cancer in adult populations. METHODS: A systematic literature review was performed by searching the EMBASE, PubMed, Scopus and International Pharmaceutical Abstract databases using terms related to vitamin A (e.g. retinol, α-carotene, ß-carotene, and ß-cryptoxanthin) and hepatic cancer without applying any time restriction. A meta-analysis was performed using random effect models. RESULTS: The meta-analysis of five studies showed no association between serum retinol and liver cancer (pooled risk ratio = 1.90 (0.40-9.02); n = 5 studies, I2 = 92%). In addition, the systematic review of studies from 1955 to July 2017 found studies that indicated no association between the intake and serum level of α-carotene ( n = 2) and ß-cryptoxanthin ( n = 1) and the risk of liver cancer. Further, the associations between retinol intake ( n = 3), ß-carotene intake ( n = 3), or serum ß-carotene ( n = 3) and liver cancer were inconclusive. CONCLUSIONS: Current information on the association between vitamin A intake and liver cancer or serum vitamin A and liver cancer are limited. Most studies demonstrated no association between dietary vitamin A and the risk of liver cancer. However, the finding was based on a small number of studies with potential publication bias. Therefore, large observational studies should be conducted to confirm these associations.

Cross-sectional associations between psychological traits, and HPV vaccine uptake and intentions in young adults from the United States.

Human papillomavirus (HPV) is the most prevalent sexually transmitted infection worldwide and can lead to the development of genital warts, and cancers throughout the body. Despite the availability of HPV vaccines for over a decade, uptake in the United States among adolescents and young adults remains well below national targets. While most efforts to improve HPV vaccine uptake have rightly focused on adolescents, there is still a tremendous opportunity to improve vaccination among young adults who have not been vaccinated against HPV. To that end, we report an exploratory examination of associations between HPV vaccination status and intentions with psychological traits that may impact HPV vaccine uptake with a national, demographically diverse sample of young adults (N = 1358) who completed an online survey. These psychological traits conceptually mapped onto motivations to: 1) understand health-related information, 2) deliberate, 3) manage uncertainty, and 4) manage threats. We found notable gender differences for the association of these motivations and vaccination status. For women, higher interest in and ability to understand health-related information seemed to distinguish those who reported receiving the HPV vaccine from those who did not. For men, less need to deliberate and greater needs to manage threat and uncertainty seemed to be the distinguishing motives for those who reported receiving the HPV vaccine compared to those who did not. Results for vaccination intentions were less consistent, but there was some evidence to indicate that, regardless of gender, greater health-related information interest and understanding and need to manage uncertainty and threats were associated with increased intention to receive the HPV vaccine, while greater need to deliberate was associated with decreased vaccination intentions. These results suggest that there are psychological differences that are associated with HPV vaccination decisions and that these motivations should be considered in efforts to improve HPV vaccine uptake.

No-Touch Disinfection Methods to Decrease Multidrug-Resistant Organism Infections: A Systematic Review and Meta-analysis.

BACKGROUND Recent studies have shown that using no-touch disinfection technologies (ie, ultraviolet light [UVL] or hydrogen peroxide vapor [HPV] systems) can limit the transmission of nosocomial pathogens and prevent healthcare-associated infections (HAIs). To investigate these findings further, we performed a systematic literature review and meta-analysis on the impact of no-touch disinfection methods to decrease HAIs. METHODS We searched PubMed, CINAHL, CDSR, DARE and EMBASE through April 2017 for studies evaluating no-touch disinfection technology and the nosocomial infection rates for Clostridium difficile, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and other multidrug-resistant organisms (MDROs). We employed random-effect models to obtain pooled risk ratio (pRR) estimates. Heterogeneity was evaluated with I2 estimation and the Cochran Q statistic. Pooled risk ratios for C. difficile, MRSA, VRE, and MDRO were assessed separately. RESULTS In total, 20 studies were included in the final review: 13 studies using UVL systems and 7 studies using HPV systems. When the results of the UVL studies were pooled, statistically significant reduction ins C. difficile infection (CDI) (pRR, 0.64; 95% confidence interval [CI], 0.49-0.84) and VRE infection rates (pRR, 0.42; 95% CI, 0.28-0.65) were observed. No differences were found in rates of MRSA or gram-negative multidrug-resistant pathogens. CONCLUSIONS Ultraviolet light no-touch disinfection technology may be effective in preventing CDI and VRE infection. Infect Control Hosp Epidemiol 2018;39:20-31.

Long-term consequences of landmine injury: A survey of civilian survivors in Bosnia-Herzegovina 20 years after the war.

INTRODUCTION: Bosnia-Herzegovina is one of the most landmine-contaminated countries in Europe. Since the beginning of the war in 1992, there have been 7968 recorded landmine victims, with 1665 victims since the end of the war in 1995. While many of these explosions result in death, a high proportion of these injuries result in amputation, leading to a large number of disabled individuals. OBJECTIVE: The purpose of this study is to conduct a survey of civilian landmine victims in Bosnia-Herzegovina in order to assess the effect of landmine injuries on physical, mental, and social well-being. METHODS: Civilian survivors of landmine injuries were contacted while obtaining care through local non-governmental organizations (NGOs) throughout Bosnia-Herzegovina to inquire about their current level of independence, details of their injuries, and access to healthcare and public space. The survey was based upon Physicians for Human Rights handbook, "Measuring Landmine Incidents & Injuries and the Capacity to Provide Care." RESULTS: 42 survivors of landmines completed the survey, with an average follow up period of 22.0 years (±1.7). Of civilians with either upper or lower limb injuries, 83.3% underwent amputations. All respondents had undergone at least one surgery related to their injury: 42.8% had at least three total operations and 23.8% underwent four or more surgeries related to their injury. 26.2% of survivors had been hospitalized four or more times relating to their injury. 57.1% of participants reported they commonly experienced anxiety and 47.6% reported depression within the last year. On average, approximately 3% of household income each year goes towards paying medical bills, even given governmental and non-governmental assistance. Most survivors relied upon others to take care of them: only 41.5% responded they were capable of caring for themselves. 63.4% of respondents reported their injury had limited their ability to gain training, attend school, and go to work. CONCLUSION: The majority of civilian landmine survivors report adverse health effects due to their injuries, including anxiety, depression, multiple surgeries, and hospitalizations. The majority also experience loss of independence, either requiring care of family members for activities of daily living, disability, and inability to be employed. Further research is required to determine effective interventions for landmine survivors worldwide.

Association between polypharmacy and death: A systematic review and meta-analysis.

OBJECTIVE: Polypharmacy has been linked to a myriad of adverse consequences, and escalating rates of polypharmacy present an emerging concern, particularly among older adults. This systematic review and meta-analysis summarizes the existing literature concerning the association between polypharmacy and mortality. DATA SOURCES: A systematic literature review was done by searching the EMBASE, PubMed, Scopus, and International Pharmaceutical Abstract databases to identify studies assessing the association between polypharmacy and death published until June 2016. STUDY SELECTION: Studies that investigated the association between polypharmacy and mortality were eligible for this systematic review and meta-analysis. DATA EXTRACTION: Data were extracted by the first and second authors independently using a data extraction form. Disagreement was resolved by consensus. A meta-analysis was performed using random effect models. Heterogeneity was assessed using the I2 statistic. RESULTS: Forty-seven studies were included in this meta-analysis. The underlying populations were heterogeneous (I2= 91.5%). When defined as a discrete variable, pooled risk estimates demonstrated a significant association between polypharmacy and death (pooled-adjusted odds ratio [aOR] 1.08 [95% CI 1.04-1.12]). When defined categorically, a dose-response relationship was observed across escalating thresholds for defining polypharmacy. Categorical thresholds for polypharmacy using values of 1-4 medications, 5 medications, and 6-9 medications were significantly associated with death (P <0.05; aOR 1.24 [1.10-1.39], aOR 1.31 [1.17, 1.47], and aOR 1.59 [1.36-1.87], respectively). Excessive polypharmacy (ie, the use of 10 or more medications) was also associated with death (aOR 1.96 [1.42-2.71]). CONCLUSIONS: Pooled risk estimates from this meta-analysis reveal that polypharmacy is associated with increased mortality risk, using both discrete and categorical definitions. The causality of this relationship remains unclear, but it emphasizes the need for approaches to health care delivery that achieve an optimal balance of risk and benefit in medication prescribing.

Risk of surgical site infection, acute kidney injury, and Clostridium difficile infection following antibiotic prophylaxis with vancomycin plus a beta-lactam versus either drug alone: A national propensity-score-adjusted retrospective cohort study.

BACKGROUND: The optimal regimen for perioperative antimicrobial prophylaxis is controversial. Use of combination prophylaxis with a beta-lactam plus vancomycin is increasing; however, the relative risks and benefits associated with this strategy are unknown. Thus, we sought to compare postoperative outcomes following administration of 2 antimicrobials versus a single agent for the prevention of surgical site infections (SSIs). Potential harms associated with combination regimens, including acute kidney injury (AKI) and Clostridium difficile infection (CDI), were also considered. METHODS AND FINDINGS: Using a multicenter, national Veterans Affairs (VA) cohort, all patients who underwent cardiac, orthopedic joint replacement, vascular, colorectal, and hysterectomy procedures during the period from 1 October 2008 to 30 September 2013 and who received planned manual review of perioperative antimicrobial prophylaxis regimen and manual review for the 30-day incidence of SSI were included. Using a propensity-adjusted log-binomial regression model stratified by type of surgical procedure, the association between receipt of 2 antimicrobials (vancomycin plus a beta-lactam) versus either single agent alone (vancomycin or a beta-lactam) and SSI was evaluated. Measures of association were adjusted for age, diabetes, smoking, American Society of Anesthesiologists score, preoperative methicillin-resistant Staphylococcus aureus (MRSA) status, and receipt of mupirocin. The 7-day incidence of postoperative AKI and 90-day incidence of CDI were also measured. In all, 70,101 procedures (52,504 beta-lactam only, 5,089 vancomycin only, and 12,508 combination) with 2,466 (3.5%) SSIs from 109 medical centers were included. Among cardiac surgery patients, combination prophylaxis was associated with a lower incidence of SSI (66/6,953, 0.95%) than single-agent prophylaxis (190/12,834, 1.48%; crude risk ratio [RR] 0.64, 95% CI 0.49, 0.85; adjusted RR 0.61, 95% CI 0.46, 0.83). After adjusting for SSI risk, no association between receipt of combination prophylaxis and SSI was found for the other types of surgeries evaluated, including orthopedic joint replacement procedures. In MRSA-colonized patients undergoing cardiac surgery, SSI occurred in 8/346 (2.3%) patients who received combination prophylaxis versus 4/100 (4.0%) patients who received vancomycin alone (crude RR 0.58, 95% CI 0.18, 1.88). Among MRSA-negative and -unknown cardiac surgery patients, SSIs occurred in 58/6,607 (0.9%) patients receiving combination prophylaxis versus 146/10,215 (1.4%) patients who received a beta-lactam alone (crude RR 0.61, 95% CI 0.45, 0.83). Based on these associations, the number needed to treat to prevent 1 SSI in MRSA-colonized patients is estimated to be 53, compared to 176 in non-MRSA patients. CDI incidence was similar in both exposure groups. Across all types of surgical procedures, risk of AKI was increased in the combination antimicrobial prophylaxis group (2,971/12,508 [23.8%] receiving combination versus 1,058/5,089 [20.8%] receiving vancomycin alone versus 7,314/52,504 [13.9%] receiving beta-lactam alone). We found a significant association between absolute risk of AKI and receipt of combination regimens across all types of procedures. If the observed association is causal, the number needed to harm for severe AKI following cardiac surgery would be 167. The major limitation of our investigation is that it is an observational study in a predominantly male population, which may limit generalizability and lead to unmeasured confounding. CONCLUSIONS: There are benefits but also unintended consequences of antimicrobial and infection prevention strategies aimed at "getting to zero" healthcare-associated infections. In our study, combination prophylaxis was associated with both benefits (reduction in SSIs following cardiac surgical procedures) and harms (increase in postoperative AKI). In cardiac surgery patients, the difference in risk-benefit profile by MRSA status suggests that MRSA-screening-directed prophylaxis may optimize benefits while minimizing harms in this selected population. More information about long-term outcomes and patient and societal preferences regarding risk of SSI versus risk of AKI is needed to improve clinical decision-making.